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1412 Fractures of the mandible or of the maxilla should be dealt with as early as possible. There is no neces- sity to wait for the subsidence of swelling, since in most cases the occlusion of the teeth will afford the most accurate guide as to the accuracy of the reduc- tion. In most of these fractures the cooperation of a dental surgeon is desirable. Healed.-Neglected fractures of the nose frequently lead to some degree of nasal obstruction as well as to the cosmetic defect. Unless the nasal arch is replaced in its normal position it is seldom possible to restore and maintain the nasal septum in a central position. It is therefore desirable to undertake restoration to the normal as soon as possible. This is particularly so in fractures occurring before the completion of growth, since persistence of the displacement will result in an aggravation of the defects. Lesser degrees of nasal injury may be the cause of severe defect. For example, a nasal fracture may be associated with little displacement, but may be followed by an infected hsematoma of the septum. This frequently results in severe deformity on account of the loss of support of the lower half of the nasal bridge. When all sepsis has been eliminated, the bridge should be supported in its correct position by a bone or cartilage graft. This is of particular importance in children, since it appears that lack of tip support is frequently followed by failure of growth of the columella and ahe. Neglected fractures of the malar zygomatic com- pound will result in persistence of some or all of the symptoms of this fracture, namely : (1) Pain on mastication. (2) Low level of the eye on the affected side with or without diplopia. (3) Anesthesia of the upper lip and anterior teeth on the affected side. It is frequently possible to mobilise the fracture and replace it. If this is not desirable or possible, then the effects of the fracture on the eye may be ameliorated by building up the orbital support by bone or cartilage graft, and the loss of contour in the malar region may be disguised by a fat graft. Neglected fractures of the mandible or maxilla are usually capable of mobilisation and reposition. If, however, a mandibular fracture has been complicated by infection and bone loss, then the whole dental occlusion has been disrupted. In this case a series of operations will possibly be necessary, having as their first aim the bridging of the defect by bone, and as the second disguise of any secondary defects which may have occurred. Loss of Special Structures The loss of nose, lips, ears, or other specialised structures, whether as the result of accident or disease, can usually be made good. As a rule these repairs must necessarily be carried out at the expense of some other part of the patient’s anatomy. In the case of an ear loss it may be desirable to utilise the cartilage from another person as the basis for the reconstruction. This leads to less defect in the donor than would be imagined. All of these reconstructive operations are as a rule a little slow, but it must be remembered that a new nose can be constructed in as short a time as three weeks. Complete reconstruction of (say) one side of the face, together with eyelids, must neces- sarily occupy considerably more time, although each operative stage is relatively short-say two to three weeks. Even though this type of work occupies valuable time and requires much patience, it is found that the patient is always cooperative. The prospect of being relieved of a deformity which precludes all social contacts is more than a sufficient incentive. Nor must it be forgotten that even a small physical lesion may be the cause of great mental distress. The removal of the lesion may be the means of avoiding or alleviating much of the chronic ill health which is associated with the abnormal sensitiveness from which these patients often suffer. H. D. GILLIES, F.R.C.S., Plastic Surgeon to St. Bartholomew’s Hospital. RAINSFORD MOWLEM, M.B., F.R.C.S., Surgeon Specialist, Plastic Unit, L.C.C. THE SERVICES ROYAL NAVAL MEDICAL SERVICE Surg. Capt. G. R. McCowen, O.B.E., to President for course. Surg. Lt.-Comdrs. A. J. Burden to Pembroke for R.N.B. ; T. F. Crean to Pembroke for R.N. Hosp., Chatham; and J. G. Currie to President for course. Surg. Lts. C. J. Mullen to Resolzction ; and B. M. O’Sullivan to President for course. ROYAL NAVAL VOLUNTEER RESERVE Surg. Lt. R. H. Longmoor to be Surg. Lt.-Comdr. Surg. Lt. W. E. Thomas to Resolution. Proby. Surg. Lt. A. I. L. Maitland to be Surg. Lt. ROYAL ARMY MEDICAL CORPS The undermentioned appt. has been made in India :- D.A.D.H. : Maj. J. N. Atkinson, R.A.M.C. Maj. T. L. Henderson, R.A.M.C., has assumed the post of specialist in surgery at Bareilly. SUPPLEMENTARY RESERVE OF OFFICERS Lt. S. D. Loxton to be Capt. TERRITORIAL ARMY The King has conferred the Efficiency Decoration upon the undermentioned Officers under the terms of the Royal Warrant dated Sept. 23rd, 1930 : Lt.-Cols. W. H. Kerr and J. M. Chrystie; Majs. W. R. Watt and H. M. Holt. ROYAL AIR FORCE Squadron Leaders F. L. White to Central Medical Establishment, London; and B. W. Cross to Aircraft Depôt, Hinaidi, Iraq. The undermentioned Flight Lts. are granted permanent commissions in that rank : F. W. P. Dixon, M.B.E., and C. R. Palfreyman. Flight Lt. C. A. Lewis relinquishes his short service commission. DEATHS IN THE SERVICES Major-General Sir GEORGE DEANE BOURKE, who died on Monday in London at the age of 84, was born in Nova Scotia to Lieut.-Colonel T. J. Deane Bourke,who married the daughter of the Ven. Robert Willis, Arch- deacon of Nova Scotia. He qualified L.R.C.P. and S.I. in 1873, and joined the R.A.M.C. in the following year, becoming colonel in 1903. He served with the Nile expedition 1884-85, in Burma 1889, and with the Chin Lushai expedition 1889-90 (dispatches and clasp). He became principal medical officer of the Western District 1903-08, and P.M.O., Irish Command, 1908-12. He was made a C.B. (mil.) in 1907, K.C.M.G. in 1917, and was hon. physician to the King from 1909 to 1912. Retiring in 1912, he went to the Balkans under the British Red Cross Society. During the European War he was re- employed as D.D.M.S. Scottish Command, and later as D.D.M.S. Aldershot Command. He married in 1883 Mary Morrow, daughter of John Stairs, formerly of Fairfield, Halifax, N.S., and has a son, Group Captain Ulick John Deane, C.M.G., R.A.F. (retd.).

THE SERVICES

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1412

Fractures of the mandible or of the maxilla shouldbe dealt with as early as possible. There is no neces-sity to wait for the subsidence of swelling, since inmost cases the occlusion of the teeth will afford themost accurate guide as to the accuracy of the reduc-tion. In most of these fractures the cooperation of adental surgeon is desirable.

Healed.-Neglected fractures of the nose frequentlylead to some degree of nasal obstruction as well asto the cosmetic defect. Unless the nasal arch is

replaced in its normal position it is seldom possibleto restore and maintain the nasal septum in a centralposition. It is therefore desirable to undertakerestoration to the normal as soon as possible. Thisis particularly so in fractures occurring beforethe completion of growth, since persistence of the

displacement will result in an aggravation of thedefects. Lesser degrees of nasal injury may be thecause of severe defect. For example, a nasal fracturemay be associated with little displacement, but maybe followed by an infected hsematoma of the septum.This frequently results in severe deformity on accountof the loss of support of the lower half of the nasalbridge.When all sepsis has been eliminated, the bridge

should be supported in its correct position by a boneor cartilage graft. This is of particular importancein children, since it appears that lack of tip supportis frequently followed by failure of growth of thecolumella and ahe.

Neglected fractures of the malar zygomatic com-pound will result in persistence of some or all of thesymptoms of this fracture, namely :

(1) Pain on mastication.(2) Low level of the eye on the affected side with or

without diplopia.(3) Anesthesia of the upper lip and anterior teeth on

the affected side.

It is frequently possible to mobilise the fractureand replace it. If this is not desirable or possible,then the effects of the fracture on the eye may beameliorated by building up the orbital support bybone or cartilage graft, and the loss of contour inthe malar region may be disguised by a fat graft.

Neglected fractures of the mandible or maxilla areusually capable of mobilisation and reposition. If,however, a mandibular fracture has been complicatedby infection and bone loss, then the whole dentalocclusion has been disrupted. In this case a seriesof operations will possibly be necessary, having as

their first aim the bridging of the defect by bone,and as the second disguise of any secondary defectswhich may have occurred.

Loss of Special Structures

The loss of nose, lips, ears, or other specialisedstructures, whether as the result of accident or

disease, can usually be made good. As a rule theserepairs must necessarily be carried out at the expenseof some other part of the patient’s anatomy. In thecase of an ear loss it may be desirable to utilise thecartilage from another person as the basis for thereconstruction. This leads to less defect in the donorthan would be imagined.

All of these reconstructive operations are as a

rule a little slow, but it must be remembered that anew nose can be constructed in as short a time asthree weeks. Complete reconstruction of (say) oneside of the face, together with eyelids, must neces-sarily occupy considerably more time, although eachoperative stage is relatively short-say two to three

weeks. Even though this type of work occupiesvaluable time and requires much patience, it isfound that the patient is always cooperative. The

prospect of being relieved of a deformity whichprecludes all social contacts is more than a sufficientincentive. Nor must it be forgotten that even asmall physical lesion may be the cause of great mentaldistress. The removal of the lesion may be themeans of avoiding or alleviating much of the chronicill health which is associated with the abnormalsensitiveness from which these patients often suffer.

H. D. GILLIES, F.R.C.S.,Plastic Surgeon to St. Bartholomew’s Hospital.

RAINSFORD MOWLEM, M.B., F.R.C.S.,Surgeon Specialist, Plastic Unit, L.C.C.

THE SERVICES

ROYAL NAVAL MEDICAL SERVICE

Surg. Capt. G. R. McCowen, O.B.E., to President forcourse.

Surg. Lt.-Comdrs. A. J. Burden to Pembroke for R.N.B. ;T. F. Crean to Pembroke for R.N. Hosp., Chatham;and J. G. Currie to President for course.

Surg. Lts. C. J. Mullen to Resolzction ; and B. M.O’Sullivan to President for course.

ROYAL NAVAL VOLUNTEER RESERVE

Surg. Lt. R. H. Longmoor to be Surg. Lt.-Comdr.Surg. Lt. W. E. Thomas to Resolution.Proby. Surg. Lt. A. I. L. Maitland to be Surg. Lt.

ROYAL ARMY MEDICAL CORPS

The undermentioned appt. has been made in India :-D.A.D.H. : Maj. J. N. Atkinson, R.A.M.C.Maj. T. L. Henderson, R.A.M.C., has assumed the post

of specialist in surgery at Bareilly.SUPPLEMENTARY RESERVE OF OFFICERS

Lt. S. D. Loxton to be Capt.TERRITORIAL ARMY

The King has conferred the Efficiency Decoration uponthe undermentioned Officers under the terms of the

Royal Warrant dated Sept. 23rd, 1930 : Lt.-Cols. W. H.Kerr and J. M. Chrystie; Majs. W. R. Watt and H. M.Holt.

ROYAL AIR FORCE

Squadron Leaders F. L. White to Central MedicalEstablishment, London; and B. W. Cross to Aircraft

Depôt, Hinaidi, Iraq.The undermentioned Flight Lts. are granted permanent

commissions in that rank : F. W. P. Dixon, M.B.E., andC. R. Palfreyman.

Flight Lt. C. A. Lewis relinquishes his short servicecommission.

DEATHS IN THE SERVICES

Major-General Sir GEORGE DEANE BOURKE, who diedon Monday in London at the age of 84, was born inNova Scotia to Lieut.-Colonel T. J. Deane Bourke,whomarried the daughter of the Ven. Robert Willis, Arch-deacon of Nova Scotia. He qualified L.R.C.P. and S.I.in 1873, and joined the R.A.M.C. in the following year,becoming colonel in 1903. He served with the Nileexpedition 1884-85, in Burma 1889, and with the ChinLushai expedition 1889-90 (dispatches and clasp). Hebecame principal medical officer of the Western District1903-08, and P.M.O., Irish Command, 1908-12. He wasmade a C.B. (mil.) in 1907, K.C.M.G. in 1917, and washon. physician to the King from 1909 to 1912. Retiringin 1912, he went to the Balkans under the British RedCross Society. During the European War he was re-

employed as D.D.M.S. Scottish Command, and later asD.D.M.S. Aldershot Command. He married in 1883 MaryMorrow, daughter of John Stairs, formerly of Fairfield,Halifax, N.S., and has a son, Group Captain Ulick JohnDeane, C.M.G., R.A.F. (retd.).